First, the governance structure of the traditional rural cooperative medical system in China
(A) the origin and evolution of the traditional cooperative medical system
In the early days of the People's Republic of China, the severe political and economic situation at home and abroad posed a great threat to national security. For the sake of national defense and military affairs, it is inevitable to imitate the model of the former Soviet Union and implement the development strategy of advanced heavy industry. However, China has a low level of economic development and a weak industrial base. Agricultural surplus products are the main original capital of national industrialization, and the country can only promote industrialization by drawing economic surplus from the countryside through the exchange of industrial and agricultural products. Therefore, in order to promote industrialization in an all-round way, urban barriers represented by household registration system have been established, and production and living resources have been stranded in cities through the ticket number system corresponding to household registration. At the same time, the dual economy and social structure have been further promoted, leading to fundamental differences in the economic and social operation mechanism between urban and rural areas. In the case of relatively scarce resources, especially in the case of industrialization-oriented, protecting the labor force in the industrial sector has become the first choice goal and value orientation of the whole public policy. [2] The state adopts the principle of differential treatment between urban and rural areas, that is, since the early 1950s, China has gradually established a medical security system that is compatible with the planned economy, and the state has provided free medical care and labor insurance medical treatment to urban institutions. However, farmers who lack medical security began to take the form of spontaneous mutual assistance to solve the problem of lack of medical care and medicine in rural areas.
The cooperative medical and health care system of mutual assistance officially appeared in rural areas of China, which was the climax of 1955 rural cooperation. A number of health stations organized by rural production cooperatives have appeared in rural areas of Shanxi, Henan and other provinces. By combining the "health care fee" paid by members with the subsidy from the public welfare fund of production cooperatives, the problem of looking down on illness has been solved. This spontaneous form of mutual assistance is short-lived, because the institutional changes in any society actually involve the adjustment and distribution of interest relations. In the composition of multilateral forces' participation, influence and transaction, different social forces will be drawn into the stage of political order, and various scattered interests will be organized and transmitted to the social and political system to avoid the accumulation of non-institutionalized forces outside the system. [3] Kirkham's research on medical care systems in developed and developing countries also shows that all governments actually implement direct and indirect management and control over medical care, whether it is socialized medical care system or decentralized medical security system. [4]
1956, the Model Charter of Advanced Agricultural Production Cooperatives adopted at the Third Session of the First National People's Congress stipulated that cooperatives should be responsible for medical treatment of their members who are injured or sick on business, and should give them working days as subsidies as appropriate, thus giving them the responsibility of collectively intervening in the medical treatment of diseases of rural social members for the first time. The symbol of the government's action on rural health issues is that after the Ministry of Health held a national rural health work conference in Jishan County, Shanxi Province in June 1959 1 1, it put forward in the report written by the Ministry of Health to the Central Committee of the Communist Party of China and its annex "Opinions on Several Issues Concerning Health Work in People's Communes": "At present, there are two main forms of medical system in people's communes. The first is to implement the collective medical system for members of people's communes. According to the current level of productivity development and the actual situation of mass consciousness, it is appropriate to implement the collective health care system for members of people's communes. " 1960 In February, the Central Committee forwarded the report of the Ministry of Health and its annexes, and thought that "the report and its annexes are very good" and asked all localities to refer to them for implementation. Since then, cooperative medical care has become a basic system for the government to implement medical and health work in rural areas of China.
1965 In September, the Central Committee of the Communist Party of China approved the report of the leading group of the Ministry of Health on giving priority to the development of rural health work, emphasizing the strengthening of rural primary health care and promoting the development of rural cooperative medical care system. The full implementation of cooperative medical care was during the Cultural Revolution after 1966. Mao Zedong personally wholesaled the experience of managing cooperative medical care in Changyang County, Hubei Province, and issued the instruction of "doing a good job in cooperative medical care". Under the political atmosphere at that time, most counties, communes and production brigades in rural areas established medical and health institutions, forming a relatively complete three-level prevention and health care network. By 1976, 90% farmers in China had participated in the cooperative medical system. Subsequently, Article 50 of Chapter III of the Constitution of People's Republic of China (PRC) adopted by the Fifth National People's Congress (No.1978) stipulates that "workers have the right to material assistance when they are old, sick or incapacitated". 1979 The Ministry of Health, the Ministry of Agriculture, the Ministry of Finance, the State General Administration of Medicine and the National Federation of Supply and Marketing Cooperatives defined the nature of rural cooperative medical care according to the Constitution and the actual situation at that time: "Rural cooperative medical care is a socialist medical system established by members of people's communes on the basis of collective strength and voluntary mutual assistance, and it is also a collective welfare undertaking for members": "According to the provisions of the Constitution, the state actively supports and develops cooperative medical care, making medical and health work better. The state gives necessary support to social teams with economic difficulties. " [5]
From the above analysis of the origin and evolution of the cooperative medical system, we can see that in the early days of the founding of the People's Republic of China, although the country did not extend the urban medical security system to rural areas, it did not let go. On the contrary, it actively intervened in the establishment of rural medical system from the outside, and incorporated the establishment of rural cooperative medical system into the whole national economic and social system. However, limited by the financial resources of the country at that time, the development path of "national rural medical system community office" was adopted for rural cooperative medical care.
(B) the governance structure of the traditional rural cooperative medical system
As the rural cooperative medical system in China is a special institutional arrangement formed in a specific historical period, it has its own unique manifestations compared with foreign social welfare systems. From the perspective of governance structure, a "cabbage" structure has been formed, in which the public assistance structure is externalized and the private assistance structure is internalized:
The externalization of public assistance structure, that is, the government's control and monopoly of medical services and medical resources supply, has played a supporting role in cooperative medical care. It mainly includes: (1) The state owns all medical institutions, and there are neither private health insurance companies nor private medical practitioners. The government quickly established a rural health network with county hospitals as the leader, including commune and production brigade medical institutions, and the government controlled all medical service supply channels. (2) The government controls all drug channels and drug prices; (3) The government is responsible for funding the prevention of endemic diseases; (4) The government is responsible for training rural doctors.
The internalization of non-governmental structure means that the government has no financial allocation to rural grassroots health institutions, and mainly relies on the production team to withdraw public welfare funds and farmers to pay health care fees to ensure the source of funds, thus realizing the prepaid community medical model of "combining doctors and preventing drug abuse". It mainly includes: (1) farmers who participate in rural cooperative medical care have to pay certain medical and health care fees; (2) Rural cooperative medical care funds mainly come from collective economy and collective economic public welfare fund; (3) The remuneration of doctors and health workers is paid by the collective economy; (4) The operation of the commune hospital mainly depends on the financial support of the commune team, while the clinic of the brigade is maintained by the collective economy. The housing and equipment of the clinic are invested by the brigade, and the working capital and personnel funds are mainly allocated by the production team; (5) In terms of management, village-to-village management, village-to-village management, joint village management and village-to-village management are implemented.
From the perspective of governance structure, the strength of public assistance structure depends on the control of medical services, the supply of medical resources and the recognition of political authority governance. The level of private operation is directly related to the strength of the collective economy and the income of farmers. Whether the governance structure of any medical system is effective depends on whether it can solve the three major problems of supply-side induced demand [6], adverse selection [7] and moral hazard [8], and also depends on whether it can solve the accessibility and availability of medical services in rural areas, and the traditional cooperative medical system has solved these problems to some extent:
(1) On the issue of supplier-induced demand, although the medical service institutions of traditional cooperative medical care providers are monopolists and price makers of medical services, the labor remuneration of doctors and health workers is paid by the collective economy; The operation of commune hospitals mainly depends on the financial support of commune teams, and the clinics of brigade teams rely on the collective economy to maintain; The housing and equipment of the clinic are invested by the brigade; Working capital and personnel funds are mainly allocated by the production team. That is to say, whether it is barefoot doctors (part-time rural health workers), commune health workers, or medical staff in medical institutions at or above the county level, their income is stipulated by the collective or the state, and the income and welfare of medical service institutions and service personnel have nothing to do with the supply of medical services, so there is no incentive mechanism to provide too many services. This has restrained the demand induced by suppliers to some extent.
(2) On the issue of adverse selection, although the traditional cooperative medical system emphasizes the principle of voluntariness, the rural grass-roots organizations under state control have solved the problem of adverse selection. At that time, political concern and strong political mobilization made the cooperative medical system gain strong external support. As a grass-roots social organization, the people's commune has completely mastered the political, economic and cultural power within its jurisdiction. It is impossible for any individual farmer to exist independently without the commune, and there is no choice at all, whether it is reverse or positive. [9]
(3) With regard to moral hazard, under the planned system, the quantity, quality and price of drugs are rationed, and the behavior of drug dealers has no influence on cooperative medical care. Similarly, the hospital is public, with no profit and income, and it is also an external variable of farmers' medical insurance. That is, the low-cost medical delivery (supply) system under the planned economy can be effectively combined with cooperative medical care, and the government can control the power of medical service and drug resource allocation and implement the low-cost supply strategy; Drug prices are also controlled by the state plan and kept at a low level. Because there is no incentive mechanism with high price and high return, barefoot doctors and medical service providers at all levels can avoid moral hazard well.
(4) With regard to the accessibility and availability of rural medical services, [10] First, the government emphasized the use of Chinese herbal medicines and technologies by revitalizing Chinese medicine, and enriched clinics and local pharmacies due to a large number of cheap Chinese herbal medicines and homemade Chinese medicines, thus reducing the expenditure of cooperative medical funds and reducing the burden on farmers; Secondly, by training barefoot doctors, the government has realized "early treatment and early prevention of diseases" and "minor illness does not leave the group and serious illness does not leave the village".
From the above analysis, we find that the rural cooperative medical system based on community financing and organization has two important foundations: first, the cooperative medical system is embedded in the social structure and institutionalized, the externalization of public assistance structure is the framework of cooperative medical operation, and political authority is its governance mechanism; Second, it is a natural coincidence that members cooperate with each other, organize themselves and organize themselves as a team.
Second, the deconstruction of the traditional cooperative medical system in the transitional period.
With the transformation of economy and society, the development of cooperative medical system has been impacted unprecedentedly and declined rapidly for many reasons:
(1) With the reform of the rural contract responsibility system and the establishment of the financial system of hierarchical management, the financing of the cooperative medical fund is facing a crisis. "Cooperation" in rural cooperative medical care refers to mutual cooperation between farmers and cooperation between collectives and individuals, and it has always been a "large share" of cooperation funded by collectives, and only a small part of individual farmers have contributed. This kind of "cooperation" has no problem in agricultural cooperation and "three suggestions and five unification", because the individual part is withheld by the collective, and the collective has enough economy to pay for the part undertaken by the collective. After the implementation of the "fee to tax" in rural areas, the collective has no right and opportunity to withhold the cooperative medical expenses, and the individual part can only be collected at home. In addition, at present, the rural population is highly mobile, and there are obvious problems in this part of the collection. There are still many economically weak areas that have become "food finance" after the "fee-to-tax reform", and many village groups are even heavily in debt, so they don't have to contribute to the "cooperation" according to their ability; At the same time, the restructuring of township enterprises has intensified the sharp decline in the accumulation of public funds, and there have been problems such as difficulties in raising funds for cooperative medical care. These problems lead to the grass-roots cooperative medical organizations becoming a mere formality or self-disintegration, resulting in the unsustainable collective cooperative medical care, individual contracting and private practice of rural doctors, and the implementation of rural preventive health care. By 1998, by the time of the second national health service survey, 87.4% of farmers in China had completely sought medical treatment at their own expense [1 1].
(2) Under the background of market transformation, the core feature of China's medical service system reform is that almost all medical service providers have changed from institutions that rely almost entirely on government financial allocations to organizations that exchange services for income, even public health institutions (such as epidemic prevention stations) are no exception. In rural areas, the medical service delivery system is privatized. According to statistics, by 1998, about 50% of village clinics in China had become individual medical points, and [12] some clinics were contracted to health workers in form, which was essentially the same as individual medical points, because the village committees gave up management. At the same time, in the case of market-oriented medical supply, the government's management and supervision of drug sales is weak. In this case, facing the market is the inevitable choice for township hospitals. However, when the medical market is not fully liberalized, individuals contract along the rural health network (township hospitals) and monopolize the rural medical market, which makes the rural medical service market irreplaceable. Whether private or public, all health service providers charge patients on a project basis. After the change of incentive structure, the problem of excessive consumption induced by suppliers has also appeared in rural medical departments, and health institutions and health practitioners at all levels no longer have the motivation to actively reduce medical expenses. Increasingly marketization inevitably leads to the most classic problem in the field of medical services: excessive consumption induced by suppliers. In rural areas, county hospitals, township hospitals, maternal and child health care institutions, epidemic prevention institutions and village clinics are all accessible to farmers. Under the condition that the operation of medical institutions mainly depends on fees, it urges medical institutions and doctors to abuse prescription rights in pursuit of their own benefits, thus inducing patients to over-consume, leading to an increase in medical expenses.
(3) In the investigation of rural areas in southern Jiangsu, we found that the original cooperative medical care system was only aimed at solving the shortage of doctors and medicines in rural areas, and advocated "one needle and one straw", with a low target. In today's affluent rural medical consumption structure, there are not only basic survival consumption, but also health care and enjoyment consumption; There is not only the demand for disease prevention and treatment, but also the expectation of pursuing comfort and quality service; There are both the pursuit of nourishing and strengthening the body and the desire to solve the risk of serious illness. In the survey, we also found that some non-infectious "geriatric diseases", such as cancer, diabetes, stroke and heart disease, have replaced infectious diseases and played the role of "health killers" in rural areas. Because these diseases are difficult (or impossible) to prevent and the cost of treatment is high, the relatively low-cost public medical policy that played an effective role in fighting infectious diseases in the early 20th century has also become unsuitable. The most crucial point is that in the face of these diseases that require expensive drug treatment, the low-cost public medical policy in the past has been difficult to work. [ 13]
Third, the governance structure of the new rural cooperative medical system.
Social welfare, as a citizen's right, was put forward and widely spread by T.H. Malache after the Second World War. The most important function of the government should be to assume the responsibility of safeguarding people's welfare. From the perspective of welfare philosophy, medical care is an opportunity, and high-quality medical care should be regarded as a right that all citizens can obtain, regardless of their living conditions or economic status. From the practice of action all over the world, medical treatment has become a part of the right to life. Because of different national conditions or national strength, all countries are more or less responsible for national medical care. The operation of medical and health care system is supported by public finance, and medical and health care services should obviously be included in the category of public goods. If we say that the principle of separating urban and rural social security systems and treating urban and rural residents differently has to be implemented under the extremely tight financial situation in the early stage of industrialization in China, then today, with the widening income gap between urban and rural areas, the serious unfair distribution of medical resources between urban and rural areas, the high medical care rate of farmers at their own expense and the increasing national financial resources, the problem of how the government can "get in place" in rural cooperative medical care is very prominent.
From 5 June to 10, 2003, the general office of the State Council forwarded the opinions of the Ministry of Health and other departments on establishing a new rural cooperative medical system (hereinafter referred to as opinions). It is emphasized in the Opinions that "the new rural cooperative medical system is a mutual medical economic system for farmers, which is guided by government organizations and focuses on co-ordination of serious diseases". That is, the government tried to transform the original community medical system into the main system of national rural medical security through the reconstruction of cooperative medical system, and chose the development path of "national rural medical system community-run"
According to the relevant provisions of the new cooperative medical system and the pilot situation in various places, the new cooperative medical system has undergone substantial changes compared with the traditional cooperative medical system:
(1) The transformation from the "public assistance" of the traditional cooperative medical system to the "public service" of the new cooperative medical system is manifested in the following aspects: First, compared with the traditional cooperative medical system that only emphasizes individuals and collectives, the biggest feature of the new rural cooperative medical system is to clarify the responsibility of the government, and invest in the cooperative medical system in the central and western regions and underdeveloped regions through central tax financing, transfer payment and local government financing. To this end, the new cooperative medical system puts forward a financing mechanism that combines individual farmers' contributions, collective support and government funding. In the Opinions, it is specified that: "The annual per capita subsidy of local finance for farmers participating in the new cooperative medical system is not less than 10 yuan. The specific subsidy standard is determined by the provincial people's government. Since 2003, the central government has arranged per capita 10 yuan subsidy funds for farmers participating in the new cooperative medical system in the central and western regions except towns, which indicates that the new cooperative medical system has begun to have the nature of cooperative insurance. Especially in poor areas, government financing plays a major role. Second, in the management system, it is clear that the county (city) is the unit for overall planning. Even the initial township (town) overall planning, but also "gradually transition to county (city) overall planning." This is different from the traditional cooperative medical system of "village-run village management", "village-run township management" and "village joint management" At the same time, according to the unified model, the new rural cooperative medical system has set up a coordination committee, county agencies and supervision institutions from top to bottom, and set up a special rural cooperative medical management institution within the health administrative department, which constitutes a pattern of government participation throughout the process.
(2) In terms of governance structure, it has changed from the "private-public assistance" governance structure of the traditional cooperative medical system to the "citizen-cooperation" governance structure of the new cooperative medical system. The "private-public assistance" governance structure of the traditional cooperative medical system is easy for people to understand and master, while the "citizen-cooperation" governance structure of the new cooperative medical system is difficult to understand and operate in practice, and the existing research is not enough to explore the connotation of this governance structure.
In our view, the governance structure of "citizens' joint organization" is not only the choice in line with national conditions, but also the development trend of social policies. In the process of treating welfare diseases in western countries, the most striking thing is the rise of "welfare pluralism". On the one hand, welfare pluralism emphasizes that welfare services can be undertaken by the public sector, profit-making organizations, non-profit organizations, families and communities, and the role of the government has gradually changed to regulate welfare services, purchase welfare services, manage and arbitrate goods, and urge other departments to engage in service supply. On the other hand, it emphasizes the participation of non-profit organizations, fills the vacuum left by the government's withdrawal from the welfare field, and resists the excessive expansion of market forces. At the same time, non-profit organizations can realize the functions of integrating welfare services, promoting the efficiency of welfare supply and quickly meeting the changes in welfare demand. The two main concepts of welfare diversification are decentralization and participation. The so-called decentralization means not only that the government transfers the administrative power of welfare services from the central government to the local government, but also from the local government to the community and from the public sector to the private sector. The essence of participation is that NGOs can participate in the provision or planning of welfare services, and welfare consumers can also participate in decision-making together with welfare providers. [14] So, in this sense, the government not only has the problem of "being in place", but also solves the problem of "positioning".
On the one hand, co-production can be said to be a repositioning of the role of the government. On the other hand, the government and non-governmental organizations form a subtle cooperative relationship. [15] that is, through the cooperation between the government and collective economic organizations, local community organizations and medical service organizations, medical services are jointly produced and provided, thus improving efficiency. In these two aspects, the key is the understanding of governance, which is profoundly expounded by Fridrikhson. He believes that the original balance between the state and society has changed. Nowadays, the public sector, the private sector and the quasi-public sector are in a crisscross network environment. This new interaction represents the sharing and cooperation of responsibilities and tasks between the public sector and the private sector, as well as this new interaction of public-private synergy. [16] In this sense, the government can't just use orders as a means of governance. It must use new tools and skills to deal with navigation and guidance, emphasizing that the national government should play a leading role. [ 17]
As can be seen from the above discussion, the government is the policy maker and supervisor of the new cooperative medical system, and it is also one of the main bodies of implementation. Farmers are not only the subject of payment and benefit, but also the subject of supervision and implementation. At present, in the new cooperative medical system, there is a phenomenon that the government's large-scale intervention replaces the previous self-government mechanism within the village community and the system of collective provision of health services; There is a tendency that the government not only manages planning and financing, but also directly manages operation and supervision, and the role of farmers has evolved into the payer of the whole cooperative medical system, which is contrary to the governance structure of the new cooperative medical system of "citizens running together". The "citizen cooperation" governance structure of the new cooperative medical system may need to be developed and improved in practice, but there are several outstanding problems that need to be discussed and solved at present:
(1) What governance mechanism is used to solve the adverse selection problem? In the process of implementing the new cooperative medical system, due to the voluntary principle, the biggest problem it faces is adverse selection. Obviously, the old, the weak, the sick and the disabled are naturally willing to participate in cooperative medical care, because they have a higher chance of benefiting. However, their income is usually low and their ability to pay is limited. Young and healthy people have higher income and stronger ability to pay, but are less likely to benefit, so their willingness to participate is lower. The result of free choice must be that a large number of healthy people are unwilling to participate, and most of the people who participate are weak and sick. Even in practice, "many families only pay for the old and weak at home to participate in cooperative medical care". [18] As rational people, farmers are most concerned about whether they can benefit from the new rural cooperative medical system and whether the new rural cooperative medical system, which focuses on serious illness, can bring benefits to themselves. Judging from the current situation, the serious illness rate of paying farmers is extremely low. According to statistics, seriously ill inpatients only account for 1-3% of the population. [65,438+09] The new cooperative medical system means that the vast majority of farmers who pay fees will not get any benefits and are not attractive to them. In order to make the cooperative medical system develop continuously, it is necessary to maintain a high coverage rate. To maintain a high coverage rate, the only way to solve adverse selection is to implement mandatory governance mechanism without increasing its attractiveness.
(2) What kind of governance mechanism is used to solve the problems of supplier induced demand and moral hazard? Under the condition of market economy, the demand induced by the supplier in the medical service market is very sufficient, and the moral hazard problem is equally serious. Faced with these medical insurance problems, we can first establish a rural medical association composed of grass-roots governments, farmers' organizations and medical institutions to fundamentally enhance farmers' bargaining power in the medical service market. In this way, when purchasing medical care services, we should adopt the complete scheme of combining prevention and treatment, combining the big (disease) with the small (disease) and giving priority to mutual insurance proposed by the rural medical association. With the government's financial subsidies and policy support, we can purchase the whole set of services of medical institutions, and the cooperative medical management institutions can fully represent the interests of the insured, negotiate with medical service providers, strive for the maximum benefits for the participants of cooperative medical care, realize the demand strategy, and change the current supply-induced demand pattern in rural cooperative medical care. Secondly, while the government manages the non-profit county-level medical institutions to dominate the rural primary medical service market, it also liberalizes the rural medical service market, strengthens the substitution of the rural medical service market, and suppresses moral hazard through the competition mechanism. Finally, in the management system of cooperative medical care, we can explore the system of "collection, management and supervision", so that the fund collection management, business management and supervision management are undertaken by the corresponding subjects, thus improving management performance.
Four. conclusion and suggestion
With the economic and social transformation, the background of cooperative medical care has undergone profound changes, and the reconstruction of cooperative medical care is at a crossroads. At present, the new rural cooperative medical system is developing in exploration. From the perspective of governance structure, "citizen joint venture" is an effective choice under the condition of market economy, but how to determine the governance mechanism and development direction has become the most critical issue. Based on the above analysis, we have the following suggestions:
(1) It is suggested to implement the compulsory cooperative medical system, control adverse selection, ensure the collection of cooperative medical fund, and make the cooperative medical system develop continuously. On the financing of the new cooperative medical system, many years of policy obstacles have been eliminated. The "Opinions" stipulate that "farmers' obligation to pay for participating in cooperative medical care and resisting disease risks cannot be regarded as increasing farmers' burden". The new cooperative medical system has the characteristics of social medical insurance, but farmers still voluntarily participate in the new cooperative medical system, which increases the possibility of adverse selection under the market economy. It increases the cost of raising individual cooperative medical insurance premiums, so the implementation of compulsory cooperative medical system should be one of the main contents of the governance of the new cooperative medical system. In the specific operation process, multiple schemes can be designed according to the standard of financing, and the corresponding treatment is also different for farmers to choose. On the object of protection, it can be a household, a natural village and so on.
(2) Encourage farmers to establish medical cooperative organizations at the grassroots level, and guide farmers' representatives to participate in the management and use of funds by establishing farmers' autonomous mutual medical management organizations to gain farmers' trust and enhance the sustainability of cooperative medical care; Introduce social professional forces to help farmers' medical cooperatives put forward a set of programs that combine prevention with treatment, combine major diseases with minor diseases, and focus on mutual insurance. With the government's financial subsidies and policy support, cooperative medical management institutions can fully represent the interests of the insured and negotiate with medical service providers, such as the salary level of rural doctors and the unit price of medical services. Therefore, the establishment of an independent organization managed by farmers themselves is to let farmers voluntarily maintain the sustainable development of this system on the basis of benefiting.
(3) Introducing the third-party management mode, that is, introducing commercial insurance institutions to be responsible for the financing and operation management of medical funds. According to the principle of "raising, management and supervision", the government is responsible for raising and managing funds, the insurance company is responsible for business management, and the health administrative department is responsible for supervision and management. Entrusting commercial insurance companies to manage cooperative medical care will help reduce management costs and improve operational efficiency. At the same time, the transparency and professional operation of commercial insurance companies can also be used to increase farmers' confidence in cooperative medical care. This form has been explored in Jiangyin City, Wuxi, Wujin City, Changzhou and other 14 counties (cities and counties) for many years, and it is still relatively successful. [20] Only in this way can we give full play to the advantages of the government and realize the fundamental transformation of the role of the government.
(4) While leading the rural primary medical service market, strengthen the substitution of rural medical service market, and realize the governance of medical service price and medical service irregularity through the possibility of multiple choices in the market. We suggest that township health organizations should be adjusted to make township hospitals operate in a market-oriented way. The adjustment of township health organizations and the adjustment of county-level medical institutions are mutually conditional. As the pillar or "outline" of rural medical network, the government should concentrate its energy and financial resources on running non-profit county-level medical institutions. Under the condition of stabilizing county-level medical institutions, township health institutions should be liberalized. Township hospitals should be allowed to separate medical treatment from prevention. In areas with relatively developed economy and transportation, after maintaining the field of preventive health care, some health centers will be merged or merged according to specific conditions. Most township hospitals can be fully liberalized and encouraged to explore the reform of property rights system and the adjustment of management mode. Encourage urban medical institutions to reorganize or chain-operate township health resources, encourage social organizations and individuals to buy hospitals with low operating efficiency, revitalize and activate idle health resources, encourage some township hospitals to turn into for-profit medical institutions, and use the revitalized assets for rural community public health. Encourage qualified enterprises, organizations and individuals to set up rural township health institutions.
(5) In the discussion of the governance structure of the new rural cooperative medical system, the accessibility and accessibility of the new rural cooperative medical system were not discussed. At present, this problem is also more prominent. Mainly reflected in: in poor rural areas, farmers' economic income is low and unstable. Without external financing assistance, cooperative medical care in poor areas will have two characteristics, either very limited funds make it difficult to establish cooperative medical care, or the established cooperative medical care is difficult to consolidate in financing. [2 1] However, in rich areas, the cooperative medical system cannot meet the multi-level and multi-faceted medical needs of the rich. Therefore, we believe that the economic foundation of cooperative medical care in rural poverty-stricken areas is weak, and medical assistance should be provided to the poor, that is, the state provides serious illness assistance to poor farmers on the basis of providing basic medical care free of charge. Most of the costs of security projects should be borne by the central and local governments. In rural areas with food and clothing, the new cooperative medical system should be implemented for the population with food and clothing. In rural affluent areas, according to the actual needs of affluent people, while exploring the rural medical insurance system, we will promote the establishment of a medical security system that integrates urban and rural areas.
About the author: Lin Mingang, born in 1967, doctor of sociology, professor of sociology department of Nanjing University.